Health inspection·April 12, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00886055. Representing the Department, HFEN # 45524. A Class B Citation was written. REGULATORY VIOLATIONS: 22 CCR § 72541-Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 2/22/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about resident death. The facility failed to implement its policy on Unusual Occurrence Reporting by not notifying CDPH local district office of Resident 1's unexpected death that occurred on 1/31/2024 after the resident was found unresponsive. As a result, CDPH was not aware of Resident 1's unexpected death and learned about from a different source. A review of Resident 1's Admission Record indicated Resident 1 was a 74 years-old male was initially admitted to the facility on 4/6/2023 and readmitted on 1/20/2024 with diagnoses that included, cachexia (weakness and wasting of the body due to severe chronic illness), severe protein-calorie malnutrition (low energy intake, weight loss, loss of subcutaneous (under the skin) fat, loss of muscle mass, fluid accumulation, and decreased hand grip strength), and malaise (a general feeling of discomfort, illness, or lack of well-being). A review of Resident 1's Progress Report Notes, dated 1/31/24 at 1:10 p.m., indicated Licensed Vocational Nurse 1 (LVN 1) found Resident 1 unresponsive and pulseless. Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) was initiated. At 1:26 p.m., paramedics arrived and took over CPR. Resident was pronounced dead in the facility at 1:46 p.m. During an interview on 2/23/24 at 4:54 p.m., the Administrator stated Resident 1's death was not expected and was not reported to CDPH. A review of the facility's policy and procedures (P&P) titled, "Unusual occurrence Reporting" with an approval effective date of 7/14/2023, indicated, "all accidents and unusual occurrences involving a resident or visitor will be documented and reported so as to meet all regulatory and insurance carrier requirements." The P&P indicated events (any event reportable to federal and state agencies as defined by those agencies) such as ...Any death. The facility failed to implement its policy on Unusual Occurrence Reporting by not notifying CDPH local district office of Resident 1's unexpected death occurred on 1/31/2024 after the resident was found unresponsive. As a result, CDPH was not aware of Resident 1's unexpected death and learned about from a different source. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.